Article in January 2014 Issue of "The Joint Commission Journal onQuality and Patient Safety"

(Oak Brook, Ill., December 19, 2013) Today, Joint Commission Resources announced the release of the January 2014 issue of “The Joint Commission Journal on Quality and Patient Safety,” featuring an article on how a hospital that implemented medication event huddles dramatically reduced the incidence of adverse drug events (ADEs).

As described by Shelly Morvay, PharmD, and her co-authors in “Medication Event Huddles: A Tool for Reducing Adverse Drug Events,” Nationwide Children’s Hospital (NCH), Columbus, Ohio, conducted more than 800 medication event huddles over three years, thereby identifying more than 3,000 improvements. ADEs, defined as injuries resulting from medical care involving medication use, accounted for approximately two thirds of reported patient harm at NCH.

The quick-investigation huddle tool was proposed as a means to engage frontline staff in identifying process improvements that might contribute to ADE elimination. In March 2010, NCH piloted the medication event huddle process in its critical care units, and in 2011, introduced the process to all inpatient units and some ambulatory clinics. Subsequently, NCH has spread the process to ADEs that occur anywhere in the organization, including all ambulatory clinics, the emergency department, perioperative areas and interventional radiology.

The 30-minute medication event huddles were initiated and scheduled within 24 hours whenever an ADE was identified, and included:

An explanation by the core huddle team leader of the huddle process;

Simulation of the ADE using the actual electronic medical record, infusion pump, pharmacy labels and other equipment or supplies;

Review of a standard list of questions to identify environmental or practice factors that may have contributed;

Assignment of identified interventions or “tests of change” to appropriate participants;

Follow-up communication about “tests of change” via email; and

Encouragement to speak with colleagues about the specific ADE and huddle experience.

In addition, the medication event huddles were used as an opportunity to promote a culture of safety, increase involvement of frontline staff and speed improvement efforts. Findings showed that the absolute number of harmful ADEs decreased by 74 percent, and the ADE rate per 1,000 dispensed doses decreased by 85 percent.

The authors stated that medication event huddles require a minimum of 0.5 full-time-equivalent nurses to review the ADEs, schedule the huddles and follow-up on completion of recommendations. While huddles do not replace a formal root cause analysis or daily safety walkarounds by leadership, they do enable a more rapid identification of the cause and subsequent intervention.

“The Joint Commission Journal on Quality and Patient Safety,” published monthly by Joint Commission Resources, is a peer-reviewed journal, available by subscription, which serves as a forum for practical approaches to improving quality and safety in health care.

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Joint Commission Resources (JCR), a not-for-profit affiliate of The Joint Commission, is the official publisher and educator of The Joint Commission. JCR is an expert resource for health care organizations, providing consulting services, educational services and publications to assist in improving quality and safety and to help in meeting the accreditation standards of The Joint Commission. JCR provides consulting services independently from The Joint Commission and in a fully confidential manner. Please visit our Web site at www.jcrinc.com.